ADDENDUM 1 Antimicrobial Dosing Guide for Febrile …...• Neutropenia: absolute neutrophil count (ANC) less than 500/mm3 or expected decline to less than 500/mm3 in 48 hours as determined

ELL CHILDREN’S MEDICAL CENTER EVIDENCE-BASED OUTCOMES CENTER

Last Updated August 2019 1

ADDENDUM 1

Antimicrobial Dosing Guide for Febrile Neutropenia Antimicrobial Dose Dosing Interval

Cefepime 50 mg/kg/dose Every 8 hours • Max dose = 2000 mg

Vancomycin 15 mg/kg/dose Every 6 hours

• Max dose = 1000 mg

• Default infusion time = 1 hour, if history of Red Man syndrome consider change to 2 hour infusion

• Consider consultation with pharmacy to determine previous dosing regimen that provided therapeutic serum drug concentrations

Tobramycin 7.5 mg/kg/dose Every 24 hours

• No max dose

• Dose based on Ideal Body Weight or Adjusted Body Weight (if Actual Body Weight 30% greater than Ideal Body Weight)

• Consider consultation with pharmacy to determine previous dosing regimen that provided therapeutic serum drug concentrations

Metronidazole 10 mg/kg/dose Every 8 hours • Max dose = 500 mg

Aztreonam 50 mg/kg/dose Every 6 hours • Max dose = 2000 mg

Meropenem 20-40 mg/kg/dose Every 8 hours • Max dose = 2000 mg

Micafungin

Weight < 25 kg: 4.5 mg/kg/dose

Weight ≥ 25 kg: 3

mg/kg/dose

Every 24 hours

• Max dose = 100 mg

Liposomal Amphotericin B

5 mg/kg/dose Every 24 hours

• No max dose

• Round dose to nearest 50 mg

• To decrease the incidence of infusion reaction consider pre-medications, must be given exactly 30 minutes prior to infusion

o Tylenol per protocol (PO) o Diphenhydramine 1 mg/kg (max 50

mg/dose, IV/PO) o Hydrocortisone 1 mg/kg (max 100

mg/dose, IV) (optional)

• To decrease the risk of nephrotoxicity consider sodium loading with normal saline bolus or continuous infusion



ADDENDUM 2

Oncology Outpatient Management for Low Risk Febrile Neutropenia

Policy for Early Discharge Home on Oral Antibiotic Therapy

Dell Children’s Medical Center of Central Texas

Children’s Blood and Cancer Center

The following are guidelines for outpatient management of patients with low risk fever and neutropenia. They

are intended to provide consistency within our practice, and not to replace good clinical judgment.

Children admitted to Dell Children’s Medical Center with febrile neutropenia can be risk stratified into low and

high risk of developing bacteremia and/or adverse events based on published literature and clinical experience.

Patients meeting criteria for Low Risk may be considered for early discharge on oral antibiotics to continue

empiric treatment for febrile neutropenia.

Definitions:

• Neutropenia: absolute neutrophil count (ANC) less than 500/mm3 or expected decline to less than 500/mm3 in 48 hours as determined by the treating oncologist.

• Fever: single oral or axillary temperature greater than 38.3°C (101°F) or two temperatures greater than 38.0°C (100.4°F) in a one hour period.

• Early discharge: For qualifying Low-Risk patients, discharge can occur as early as 36 hours after admission.

• Recurrent fever: single oral or axillary temperature ≥ 38.0°C (100.4°F). • Bone marrow recovery: at least two consecutive increasing ANC values and last ANC > 100/mm3.

Eligibility:

Inclusion:

1. Family must live within 1 hour radius of DCMC. 2. Family is reliable and will call for recurrent fever, worsening condition, or with any concerns. 3. Family has telephone access. 4. Family has adequate transportation to return to clinic for appointments and for any new fever. 5. Age ≥ 1 year. 6. Afebrile ≥ 24 hours. 7. Negative blood cultures for at least 36-48 hours. 8. Able to take oral antibiotics. 9. Well-appearing (i.e. normal vital signs for at least 12 hour prior to discharge).

Exclusion:

1. Age < 1 year. 2. Diagnosis of Trisomy 21. 3. AML. 4. Infant ALL. 5. ALL in Induction or not yet in remission. 6. ALL relapse (any time prior to maintenance therapy). 7. Intensive B-NHL/relapse Leukemia protocol. 8. BMT. 9. Intensive chemotherapy regimens likely to cause prolonged neutropenia (i.e. neutropenia >7-10 days).



10. Any hemodynamic instability at presentation requiring interventions (i.e. fluid resuscitation, inotropes).

11. New onset abdominal pain, mucositis (requiring IV narcotics), or perirectal/other soft tissue abscess. 12. Evidence of respiratory changes at presentation (i.e. hypoxia, distress, compromise, pneumonitis). 13. Altered mental status, neurological changes, or irritability/meningism. 14. Not tolerating oral (including oral medications). 15. Evidence of focal infection (bacteremia, pneumonia, cellulitis, typhlitis, etc.). 16. History of ICU admission with prior febrile neutropenia episode. 17. Readmission after discharge as “Low Risk” patient. 18. Non-adherence and/or social concerns.

Antibiotic Guidelines:

If a child meets eligibility for early discharge, they may be discharged on one of the following antibiotics. The

selection of home antibiotics may depend on insurance coverage. Recommend initiation of oral antibiotics prior

to discharge so that patient takes at least one dose prior to discharge to demonstrate tolerability.

Antibiotics should be continued until evidence of bone marrow recovery.

1. Preferred: ciprofloxacin,

• 10mg/kg/dose (max dose 750mg) PO BID.

• Oral suspension cannot be given via feeding tubes because the suspension is oil-based and adheres to the feeding tube; however the tablets can be crushed and safely given via feeding tubes.

• Available dosage forms o Tablets: 100mg, 250mg, 500mg. 750mg. o Oral suspension: 250 mg/5 mL (100 mL), 500 mg/5 mL (100 mL)

2. Alternative: levofloxacin,

•



a. Family to be given thermometer at discharge b. Family to check temperature 2-3 times per day at home and any time they suspect a temperature.

c. If patient has a fever they will return immediately to CBCC outpatient clinic or ER for DCMC readmission.

Discharge checklist:

All of the following must occur prior to discharge:

• Patient and family must meet eligibility criteria.

• Family has home antibiotics in hand prior to discharge. It is preferred to have the antibiotics filled at Seton Central Outpatient Pharmacy (SCOP).

• Parent information sheet must be given to family and reviewed with them.

• Documentation by the provider in the medical record that the parent information sheet was given and reviewed, that patient meets eligibility criteria, and antibiotics have been given to family.

• First follow-up appointment must be scheduled and entered in patient’s depart plan.

• Email must be sent to hemeonc.signout informing nursing and clinic staff of patient’s discharge and plan for close outpatient follow up.

Guidelines for readmission:

1. Recurrent fever 2. New exam findings for focal infection 3. Not tolerating or not adherent to oral antibiotics 4. Respiratory distress 5. Non-adherence to phone or clinic follow-up 6. Blood culture turns positive 7. Physician concern

References:

1. Gea-Banacloche J. Evidence-based approach to treatment of febrile neutropenia in hematologic

malignancies. Hematology Am Soc Hematol Educ Program. 2013;2013(1):414–422.

2. Lehrnbecher T, Phillips R, Alexander S, et al. Guideline for the Management of Fever and Neutropenia in

Children With Cancer and/or Undergoing Hematopoietic Stem-Cell Transplantation. Journal of Clinical

Oncology. 2012;30(35):4427–4438.

3. Freifeld AG, Sepkowitz KA. No place like home? Outpatient management of patients with febrile

neutropenia and low risk. J. Clin. Oncol. 2011;29(30):3952–3954.

4. Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in

neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America. Clin. Infect.

Dis. 2011;52(4):427–431.

5. Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in

neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin. Infect. Dis.

2011;52(4):e56–93.



ADDENDUM 3

Low Risk Fever Neutropenia Oncology Patient Discharge Information IMPORTANT PHONE NUMBERS OF YOUR HEALTH CARE TEAM: Children’s Blood and Cancer Center: 512-628-1900 (Monday – Friday 7am-5:30pm) Medlink answering service: 512-323-5465 (ask for on-call pediatric oncologist) (Nights/Weekends/Holidays) Prior to discharge: you are required to have:

• A thermometer for home use

• Antibiotic prescription in hand

• Adequate transportation to return to CBCC for follow up or DCMC for admission

• Working phone number to receive daily calls from the CBCC nurse or nurse practitioner

• Follow up appointment scheduled with CBCC Instructions for home

• Check temperature 2-3 times a day AND any time you suspect a fever Notify your oncology team if temperature is 100.4 or higher

• Follow up with your oncology team at the CBCC at least twice a week until lab counts recover Next follow up appointment: ________________

• Plan to stay within a one hour driving distance from DCMC

• You will return immediately to CBCC outpatient clinic or DCMC ER for readmission if fever returns before counts have improved

Antibiotic Instructions Give Ciprofloxacin _____mg_____times a day Give Levofloxacin _____mg_____times a day Give _________________________________ Do NOT stop taking your antibiotics until instructed by your oncology team Take antibiotics on an empty stomach Oral magnesium and antacids should not be given within two hours of oral antibiotics CALL YOUR HEALTH CARE TEAM RIGHT AWAY IF YOUR CHILD HAS:

• Fever of 100.4 or higher-do not give Tylenol until doctor instructs you to. Do NOT give Motrin.

• Other signs of infection such as pain, redness or swelling anywhere in the body (sore throat, ear ache, stiff neck, pain when urinating or having bowel movements, pain or redness at broviac or port-a-cath site), or chills.

• Bleeding, including a nose bleed, bleeding from the gums that does not stop with 5-10 minutes of gentle pressure, blood in urine or stool, vomit or stool that looks black, easy bruising, or tiny red, freckles on the skin.

• Difficulty breathing

• A change in behavior or level of consciousness. Being very sleepy and being very irritable, or not making sense while talking.

• Sudden change in vision or severe headache

• Vomiting or diarrhea three times in 24 hours, or not being able to eat or drink.

• Problems with central line

• Severe mucositis (mouth sores), or is unable to eat or drink. The doctor may instruct you to go to the emergency room at Dell Children’s Medical Center or to the CBCC. If you go to the ER, wear a mask and tell the ER nurse and doctor the above information. Make sure they know your child cannot have a urinary catheter, rectal temperatures, enemas or suppositories, If your child has a fever, the team should begin your child on antibiotics as soon as possible. Parent signature________________________________ Nurse Signature _________________________
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ADDENDUM 1 Antimicrobial Dosing Guide for Febrile …...• Neutropenia: absolute neutrophil count (ANC) less than 500/mm3 or expected decline to less than 500/mm3 in 48 hours as determined